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research needs to be done in this area to detect and remedy the errors/mistakes. Patient caredelivery needs to change from a system of punitive solutions and blame to a system approachfocusing on health work environments and positive patient outcomes. Reason (2000) describes asystem approach that looks at errors as opportunities to improve process and remove many of thenegative approaches that lead to fear, blaming, and shaming. The premise is that "we cannotchange the human condition; we can change the conditions under which humans work" (p. 768).The most alarming thing about medication errors is that they occur more often invulnerable populations. "Critically ill patients are prescribed twice as many medications aspatients outside of the intensive care unit (ICU) and nearly all will suffer a potentially life-threatening error at some point during their stay" (Moyen, Camir6, & Stelfox, 2008, p. 1)."Medication dosing errors are more common in pediatrics than adults because of weight-baseddosing calculation, fractional dosing (e.g., mg vs. Gm), and the need for decimal points"("Preventing Pediatric Medication Errors," 2008, p. 1). The rate of potential adverse events maybe as much as three times higher in pediatrics and many were preventable or could have beenidentified earlier. ICU patients are also at risk because they "are prescribed twice as manymedications" as others (Moyen et al., 2008, p. 208) and ICU patients have many more IVinfusions.Medication dose calculation errors are among the various types of medicationadministration errors. Several researchers agree that one in six medication errors involvecalculations (Capriotti, 2004; Lesar, Briceland, & Stein, 1997). Medication calculation errors arebetween 7%-14% of all medication errors (Polifroni, McNulty, & Allchin, 2003). The ORManager (2006) indicates that "patients in the operating room (OR) received the wrong amountof a drug... 33% of errors in children versus 16% in adults" and "in the PACU [post anesthesia